Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | RI-W1009040752 | CA |
NPI | 1003117284 |
---|---|
Provider Name | Ms. Melany A Wallace |
First Address | Long Beach, CA 90813-5035 |
Second Address | Long Beach, CA 90813-5035 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/11/2010 |
Last Update Date | 04/11/2010 |